Provider Demographics
NPI:1134597404
Name:WIRTA, ALEXANDER (PT)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:WIRTA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:19017 120TH AVE NE BLDG 1
Practice Address - Street 2:SUITE 111
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-9510
Practice Address - Country:US
Practice Address - Phone:425-489-3420
Practice Address - Fax:425-489-3421
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT 60555817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1134597404Medicaid
WAG8964999Medicare PIN